June ID Update

Sanford Guide ID Update features current developments in infectious diseases, curated by the Sanford Guide Editorial Board. Links marked with an asterisk (*) provide details to Web Edition subscribers, while all other links are universal. If you received this message from a colleague, subscribe now.
 

June 2019

CDC Health Advisory

  • CDC is expecting a 3 to 10 month nationwide shortage of Aplisol (Par Pharmaceuticals), one of two purified-protein derivative (PPD) tuberculin antigens that are licensed by the US FDA for use in performing tuberculin skin tests (TSTs). The time frame is the manufacturer's current estimate and is subject to change. Suggested approaches for dealing with the shortage include substituting IGRA blood tests for TSTs, using the other licensed product (Tubersol), and prioritizing allocation of TSTs in consultation with state and local public health authorities. Further information can be found on the CDC website.

Practice Pearls

  • Kounis syndrome, first described in 1991, is an unusual hypersensitivity reaction to various allergens, including drugs, that results in vasospasm of the coronary arteries. It is also known as allergic angina or allergic MI. There are three types. In type I, patients have normal coronary arteries, no predisposing factors, and no elevation in cardiac enzymes. Type II occurs in patients with inactive underlying coronary artery disease in whom the allergic episode results in vasospasm without cardiac enzyme elevation. Type III includes coronary artery stent thrombosis secondary to the allergic episode. Kounis syndrome manifests with signs and symptoms of myocardial ischemia and is potentially life-threatening if not recognized promptly. Treatment begins with discontinuation of the causative agent, but there is no consensus as to the value of administering drugs that dilate the coronary arteries or suppress the allergic response. Many case reports of Kounis syndrome associated with beta-lactams, most commonlyamoxicillin, have been published. A recent report describing type I Kounis syndrome in a patient receiving a preoperative dose of vancomycin for surgical management of a gangrenous toe is only the second to implicate that drug (Am J Emerg Med 2019 June 3 [Epub ahead of print]).

New or Updated Treatment Guidelines

  • Guidelines for the diagnosis and management of CMV infection in patients following hematopoietic stem-cell transplantation and in patients receiving other types of therapy for hematological malignancies, from the 2017 European Conference on Infectious in Leukemia (ECIL 7) (Lancet Infect Dis 2019 May 29 [Epub ahead of print]).
  • 2019 guidelines for the management of tuberculosis in adults living with HIV, from the British HIV Association (HIV Med 20 Suppl 6: s2-s83, 2019). These guidelines update the 2011 version and are available on the journal website.
  • Guidelines from the French scientific societies for the biological diagnosis, treatment, persistent symptoms after documented or suspected Lyme borreliosis (Med Mal Infect 2019 May 30 [Epub ahead of print]).
  • Updated guidelines for the diagnosis, prevention and management of varicella zoster virus (VZV) in the pre- and post-transplant period, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 June 4 [Epub ahead of print]).
  • Updated guidelines for the diagnosis and management of Candida infections in solid organ transplant recipients, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 June 2 [Epub ahead of print]).
  • Updated guidelines for the diagnosis, prevention, and management of intestinal parasites in the pre- and post-transplant period, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 30 [Epub ahead of print]).
  • Updated guidelines for the epidemiology, diagnosis, prevention and management of methicillin-resistant Staphylococcus aureus (MRSA) infections in solid organ transplantation, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 23 [Epub ahead of print]).
  • Updated guidelines for the management of intra-abdominal infections in solid organ transplant recipients, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 18 [Epub ahead of print]).
  • Updated guidelines for the diagnosis, prevention, and management of infections due to multidrug-resistant (MDR) Gram-negative bacilli in the pre- and post-transplant period, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 18 [Epub ahead of print]).
  • Updated guidelines for the epidemiology and management of human papillomavirus (HPV) infections in solid organ transplant recipients, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 11 [Epub ahead of print]).
  • Updated guidelines for the epidemiology, diagnosis, prevention and management of nontuberculous mycobacterial infections in the pre- and post-transplant period, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 11 [Epub ahead of print]).
  • Updated guidelines for the diagnosis, prevention and management of Pneumocystis jiroveci fungal infection in solid organ transplant recipients, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 11 [Epub ahead of print]).
  • Updated guidelines for the diagnosis, prevention, and management of post-operative surgical site infectionsin solid organ transplantation, from the Infectious Diseases Community of Practice of the American Society of Transplantation (Clin Transplant 2019 May 11 [Epub ahead of print]).

Drug Shortages (US)

  • Antimicrobial drugs or vaccines in reduced supply or unavailable (as of June 11, 2019) due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons:
    • [New on the list since May 4]: Sulfanilamide 15% vaginal cream 
    • [Shortage recently resolved]: Amphotericin B injection, Nelfinavir tablets
    • [Continue to be in reduced supply]:
      • Aminoglycosides: Amikacin injection, Gentamicin ophthalmic ointment (unavailable), Tobramycin injection
      • Carbapenems: Meropenem injection
      • Cephalosporins: Cefazolin injection, Cefepime injection, Cefotaxime injection (unavailable), Cefoxitin injection, Ceftazidime injection, Ceftriaxone injection, Cefuroxime injection
      • Fluoroquinolones: Ciprofloxacin 0.3% ophthalmic solution, Ciprofloxacin oral suspension, Gemifloxacin tablets
      • Glyco-, glycolipo-, lipopeptides: Daptomycin injection, Vancomycin injection
      • Macrolides/azalides: Azithromycin injection, Azithromycin ophthalmic solution 1% (unavailable), Erythromycin lactobionate injection (unavailable), Erythromycin 0.5% ophthalmic ointment
      • Penicillins: Ampicillin/sulbactam injection, Piperacillin/tazobactam injection
      • Tetracyclines: Doxycycline hyclate injection
      • Other antibacterials: Clindamycin injection, Metronidazole injection, Mupirocin calcium 2% cream, Mupirocin calcium 2% nasal ointment (unavailable), Nitrofurantoin oral suspension
      • Antifungal drugs: Clotrimazole 10 mg oral troches, Fluconazole injection, Nystatin oral suspension
      • Antiparasitic drugs: Pentamidine isethionate
      • Antiretroviral drugs: None
      • Antiviral drugs: Cidofovir injection (unavailable), Letermovir injection (unavailable), Valganciclovir oral powder for solution
      • Vaccines: Hepatitis A vaccine inactivated, Hepatitis B vaccine recombinant, Zoster vaccine recombinant (Shingrix), Yellow Fever vaccine (YF-VAX is unavailable, but Stamaril can be obtained through a limited number of clinics in the US. Click here).
  • Antimicrobial drugs newly discontinued: Quinidine gluconate IV (in December 2017). Product distribution will continue until expiration of current stock (March 2019).
    • Recent discontinuations: Terbinafine granules (in May 2017), MenHibrix (in February 2017), Elvitegravir (Vitekta, in December 2016), Peginterferon alfa-2b (in February 2016; 50 mcg vials still available in limited quantities), Boceprevir (in December 2015), Permethrin 1% topical lotion (in September 2015)
  • For detailed information including estimated resupply dates, see http://www.ashp.org/menu/DrugShortages